Derek Twigg: Let me say to my hon. Friend that we are very proud of the work that the UK armed forces do and that the Welsh play a very important part in that. I pay tribute to their contribution to the armed forces and to their magnificent and outstanding achievements in Iraq and Afghanistan. My hon. Friend specifically mentioned the1st and 2nd Battalion the Royal Welsh, and there are also the Welsh Guards, who returned from Bosnia. It is very important to recognise what our armed forces do throughout the UK and that they are given a proper welcome home. We have seen examples of that recently and I am delighted to support them.

Des Browne: As Secretary of State for Defence, my departmental responsibilities are to make and execute defence policy, to provide the armed forces with the capabilities they need to achieve success in the military tasks in which they are engaged at home and abroad, and to ensure that they are ready to respond to the tasks that might arise in the future. I have today made written ministerial statements on the signing of a contract forthe purchase of a sixth C-17 Globemaster aircraft to be delivered in 2008, and on the letting of a contract for the future provision of marine services to the Royal Navy.

John Penrose: I thank the Minister for giving way. Does he agree that it is possible that a court can be more thorough in its initial investigation, particularly of the financial circumstances surrounding the break-up of a relationship? As a result, the court order—a minute of agreement in Scotland—that is created may result in a fairer and better division of assets, or provision of maintenance. Providing whoever feels hard done by the with the opportunity to undo that arrangement may result in a less just conclusion.

Michael Weir: It is enforceable in the same way as a court decree. The situation is slightly worse than the hon. Gentleman suggests. If there is an effective court decree that can be enforced by the use of sheriff officers, bailiffs or whoever is used in England for such matters, with arrestment of bank accounts and all the paraphernalia of enforcing decrees, the process can be relatively quick. If that option is not available and it is necessary to go back to CMEC, the process has to start from the beginning again. CMEC might be super-efficient and get things done quickly, but the history of the CSA does not bode well, given that many cases have lain with it for months, if not years, during which time no maintenance has been paid and arrears have escalated, which becomes a serious problem because when enforcement is attempted the arrears are astronomical and the absent parent will go to any lengths to avoid paying them.
	As I said, the innovation was widely welcomed, and rightly so. I stress, as did the hon. Member for South-West Bedfordshire (Andrew Selous), that the number of people wanting to enter into a minute of agreement that goes beyond the statutory scheme will probably be low, but it is an important group and it is important to provide choice. However, as things stand under the current legislation, this will have little impact because the minute continues to be restricted to one year. Sir David Henshaw recommended that that rule be abolished. One of the hopes as regards the reform of the CSA was that many more people would enter into minutes of agreement, but retaining the 12-month rule puts a restriction on the number who can do so. I think that the Minister will be disappointed by the number who go on to use minutes of agreement. The Public and Commercial Services union has raised concerns as to whether the numbers that he has projected, which underpin future reductions in staffing, will be met. There is an historical perspective to this in that the original 1991 Act envisaged the Child Support Agency taking over all cases of child support from the outset, which proved well beyond its capabilities. The present one-year rule was introduced to give it a breathing space, and that has now been in existence for seven years because the agency was never able to catch up.
	If we are to move forward, we all agree that it is important to get maintenance for children and to get an agreement that is in the best interests of children. The Minister seems to have tunnel vision on the matter; he is looking at only one item. It was the same in the old CSA, which overturned agreements that worked quite well because it was obsessed by the revenue stream, rather than considering the whole circumstances of the family. If we are to allow separated couples to reach agreement, we must allow them some freedom to reach an agreement that suits their circumstance.
	If we proceed with the Bill as drafted, no one in their right mind is likely to enter into an agreement that deviates from the child maintenance levels set out in it, despite the fact that we were clearly told in evidence sessions that many parents wish to consider alternatives. I quote Hilary Reynolds, who I think is the civil servant in charge of the Bill:
	"It is worth noting that when we have talked to some clients about what they find important in a voluntary agreement, sometimes it is not regular payments, but lump sums, mortgage or school uniform payments, or whatever. What suits the parents of the child or children will be a variety of things, not just the standard x amount per period." ——[Official Report, Child Maintenance and Other Payments Public Bill Committee, 17 July 2007; c. 29.]
	We also have to remember that when couples with children separate, the agreement comes at a very traumatic period. They are often very wounded, and we are asking them to negotiate an agreement. We need to give them the confidence that the agreement negotiated will be adhered to. I reiterate the point that I made in an intervention on the Minister. As things stand, even under new clause 2—I do not oppose it, but I do not think that it changes the law—parties can still enter into an agreement, and a year and a day later, one of those parties can say unilaterally, "It doesn't matter. This has all worked fine, but I've decided I don't like it any more. I'm going to the commission and asking them to overturn it." The history of the CSA is that many minutes of agreement were overturned because it just looked at the application of the payment for child maintenance. It did not take into account any transfers of capital, transfers of the matrimonial home, transfers of business or anything else, which led to a great deal of problems.
	The hon. Member for Rochdale made the point that research has shown that many agreements were property-driven, which is probably correct because they were bound by capital payments. Sometimes, however, the property is the only large asset there is, and in many cases where a couple are separating, the other party disappears off the face of the Earth as soon as the separation is through. A house is an asset—that is why we have mortgages. It is sitting there, immovable. In many cases one party would very much like to get the house before the other party disappears. The Minister's objection in Committee, which is coming through again today, seems to be the fear that such agreements will be used to get around obligations for child maintenance. None of us wants to see that happen. We all want both parents to adhere to their obligations. We are all trying to get to the same thing, but the Minister is transfixed by that fear. I do not believe that his fear would be realised. Such minutes of agreement, in my experience in my previous life, are not set in stone. They contain provisions for amendment through passage of time or change of circumstances.
	We all recognise that child support is a long-term matter. It is not for one year or five, but for 15, 16 or 17 years. There are some parents who will go to extraordinary lengths to avoid paying for their children. Frankly, however, it does not matter what rules are in place; those who are prepared to do that will still be prepared to do it. The new agency should be concentrating its fire on those cases. Those parents who accept responsibility and are prepared to enter into a sensible agreement should be allowed to do so, and to do so in terms that fit their circumstances. I mentioned the problems with the old agency overturning such agreements and if the rule remains in the current form, the problem will continue. CMEC could do exactly the same and the same problems will arise. No one will enter into a minute of agreement on other than the standard terms.
	After Committee, I tried to think about the Minister's objections to the amendments that I tabled. That is why amendment No. 1 takes its present form. I tried to incorporate some terms that would alleviate the Minister's concerns. I made it clear that there must be independent legal advice before the agreement is signed. The husband cannot say to the wife, "Sign the document, or else," or put pressure on her. They have to receive proper legal advice. I have also made it clear that the agreement must contain
	"provisions for the maintenance of any children whether by regular payments, transfers of capital or a combination of the two".
	It must address the point of maintenance for children.
	The agreement must also contain provision
	"to reconsider any regular payments in the event of a material change of circumstances".
	If circumstances change, as they do over a large number of years, the parties can reconsider the minute of agreement. They can do so through the courts or, if trust has built up over the years, they can adjust it themselves with appropriate legal advice. The provisions should be enforceable in the court. As I said at the beginning, a minute of agreement, if registered in the books of council and session, can have the same impact as a court decree.
	I do not argue that such agreements will be for everyone. Nor do I believe that they are likely to be the norm. They will be for a minority, but it could be a significant minority. They offer a realistic and effective way of dealing with child maintenance without involving the agency. They would take people out of the system and allow them, between themselves, to come to a reasonable agreement. That is behind the idea of allowing minutes of agreement in the first instance rather than involving the agency and all the bureaucracy and problems that there have been. That is why I drafted the amendment to lay down strict conditions that deal with the problems foreseen by the Minister. I hope that he will think again. We should be prepared to allow parents who can do so to enter into such agreements and not insist on the state dictating terms because of the fear that some feckless fathers will use it to get round their responsibilities. Let us try to get that right now, otherwise the problem will continue under CMEC as it did under the CSA.

John Penrose: It is all right, Mr. Speaker. I am prettier than my hon. Friend.
	I rise to agree with all the points that have been made in opposition to the Minister's points, particularly the points of principle, and to add two small points to those that have already been made by those on this side of the House.
	First, I am concerned that the Minister tried to justify his position by saying that he believes that it is important to allow people recourse to CMEC if a minute of agreement or court order is no longer working—I paraphrase. As has been ably pointed out, there are plenty of recourses and remedies, if that situation should arise, that do not require people to go back to CMEC. There are plenty of courses that people can use via the courts to vary an agreement that do not require them to go back to CMEC. There does not have to be a mandatory solution for people to go off to CMEC just because court orders or minutes of agreement are likely to fall over and leave people with no maintenance—I think that that was the phrase that he used. That situation is not likely to arise, because the courts will ensure that it cannot. I am stuck when it comes to understanding what mischief the Minister is trying to avoid. I suspect—I fear—that he is trying to avoid allowing any sort of agreement that diverges from the Government's preferred set of purely revenue-based solutions. Why is not he willing to trust the people who are best placed to work out what is right for them—the two separating parents, who have the blood connection with the child—on the assumption that they are being properly legally advised, through court proceedings, on both sides? It is not a big thing to ask. I believe hon. Members should trust the people who put us here, and trust that they are being carefully advised. I fear that the Under-Secretary is worrying about people disagreeing with the Government's preferred Revenue-based solution rather than trying to provide them with a genuine choice.
	Even if the Under-Secretary does not agree with that basic point of principle, may I at least ask him to tackle two technical points, which may be about to hit him on the back of the head if he does not accept some of the more broad-based points that the Opposition are making? If, as he has enunciated in the past, he genuinely wants to reduce the number of cases going to CMEC compared with the number that the CSA handled, does not it make sense to try to allow as many people as possible to choose the route of minutes of agreement or court orders rather than providing a method of undermining those and therefore driving people back to CMEC after a year and a day? Does not he accept that the number of cases coming to CMEC is likely to be higher in future than it would otherwise have been?
	It would also be helpful if—either in the Bill or through regulations—the Under-Secretary tried to explain and define in a bit more detail what he means by a minute of agreement or a court order that is not working. Can he put boundaries around that? For example, the Government have already accepted that they do not wish people to be able to vary their maintenance agreements if their income has changed by less than 25 per cent. up or down. Yet, a year and a day after a court order or a minute of agreement was made, if the income of the parent who pays the maintenance had increased by, for example, 15 or 20 per cent., and would not, under the Government's existing scheme, be eligible for a CMEC-based change to maintenance, the parent with care could request a new order under CMEC because they would get more money under the new regime through the increase in the income of the parent without care, which had nevertheless not increased by as much as the Government determined in the Bill was an appropriate amount to allow for a variation in the payments. Surely that would be a breach of the Government's attempts to limit the number of changes of circumstances and times that people have to go back to CMEC.
	If the Government are willing to accept the principle of variation of income for CMEC cases, should not they also be willing to define the circumstances in which a court order or a letter of agreement can be varied before people can return to CMEC? Will not the Government at least put some boundaries around that, so that it is not simply a question of the parent with care being able to go back to CMEC under any circumstances? Surely the Government should be willing to place limits on that, even if they are not willing to accept the broader principles that the Opposition have expressed.

Andrew Selous: I am sure that the Government will agree with the objectives of the new clause, which are primarily to ensure that CMEC is reminded of its specific and important obligation to chase up and secure the historical arrears of child support liability. The arrears able to be collected and paid are reckoned to be £1.4 billion. That massive sum should have been paid through to the children of this country but has not, and we are determined that it will not be forgotten or pushed under the carpet.
	I accept the Government's genuine commitment to this area of debt, and I do not doubt either the veracity of what the Minister said in Committee or his intention. CMEC will be a non-departmental public body and it is vital that this matter of debt is included in the Bill. That is why we have adopted the draconian approach of proposing to remove clause 2 and drafting new clause 3. The Minister will recognise much of clause 2 in new clause 3. He will be pleased that we have not really proposed removing anything—we have merely proposed adding the highly important requirement that the historical debt should be recorded in the Bill.
	We have also proposed that "every child" should have a right to continue
	"to share in the income and prosperity of both parents throughout their childhood".
	Clause 2 has a slightly different wording. It aims
	"to maximise the number of those children...for whom effective maintenance arrangements are in place."
	The Minister may think that we are merely proposing a small change of words, but the phrase "every child matters" is significant—he will recognise it from elsewhere within his Government.
	It is important to focus on the issue of debt. In June, 881,300 non-resident parents were in arrears, 91,470 of whom owed £10,000 or more. Some of my constituents have debts of £30,000 to £40,000 owed to them, which they want paid over to their children. We welcome the CSA's operational improvement plan target to collect an additional £213 million of debt by March 2009, but we want CMEC's instructions in this regard to be clear in the Bill.
	The CSA's 2006-07 annual report has not yet been published, so we do not know the current level of debt. The report is overdue, and we hope that it will be published soon.
	In Committee, Ministers described effective maintenance arrangements as those that are working, where money is flowing and in which parents meet their financial responsibilities. That is right as far as it goes, but it contains no reference to the historic debt. Indeed, it refers to cases with a continuing maintenance obligation, and in many cases of debt there may be no current maintenance liability, perhaps because the child has left secondary education or is living with the former non-resident parent.
	A generation of children have lost out on the vital financial support that Parliament said they should have because of the failure of the non-resident parent to pay child support and the failure of the CSA to enforce those liabilities. Those debts must not be forgotten. Non-resident parents must not be allowed to escape their obligations. The legacy of failure cannot be simply brushed aside as many families are still owed large amounts of money.
	The CSA already has an enormous armoury of enforcement weapons at its disposal and it has not always used it with sufficient rigour in the past. The problem has not been a lack of tools, but the fact that debt collection and enforcement has not been as high a priority as it should have been in the CSA. The processing and collecting of current maintenance was given higher priority. New clause 3 would ensure that past debt has equal priority, and that would be laid down in primary legislation.
	When the new commission configures its business model, it should do so around two equal objectives—the responsibility to establish and actively support continuing child maintenance, and the responsibility to collect past debts. On that basis, I hope that the Minister will look favourably on new clause 3.

Paul Rowen: I shall speak to new clause 7 and amendment No. 17. The latter would do what the hon. Member for South-West Bedfordshire (Andrew Selous) seeks to achieve with new clause 3, and we will support him if he chooses to press that to a Division. We made the point in Committee that the new commission must make a commitment to the collection of historic debt.
	On the basis of figures from March 2006, £3.5 billion has not been collected by the CSA, and the total rises by £20 million a month. That is according to last year's CSA report, and the 2006-07 report will probably show a further increase. We all have examples of non-resident parents who have gone missing and owe the parent with care tens of thousands of pounds. A lady who came to see me last year is owed £24,000, which has placed a huge burden on her. It means that her children are not getting the support that they deserve and the non-resident parent has got away with evading his responsibilities.
	We have all signed up to the main aim that CMEC should be a fresh start—a clean break from the CSA and the failures of the past. Some of us argued that it might be better if the past debt were dealt with by a residuary rump, which could concentrate solely on that. The Government did not come to that decision, but it is important that CMEC's objectives should state clearly that it has a major commitment to clearing that historic debt.
	A generation of children has already grown up without the benefit of the support that the CSA was supposed to provide for them. They have gone through the system, but in establishing CMEC we need to ensure that the actual collection of the historic debt has equal priority with the new arrangements for a new generation of children. As the hon. Member for South-West Bedfordshire said, almost 100,000 of the 881,300 non-resident parents with arrears owe more than £10,000. That is a huge amount, so it is important that we make that debt a major priority.
	New clause 7, which we shall press to a vote, would make provision for Parliament to approve the operational plan. The plan would have to be laid before Parliament by the Secretary of State and considered by both Houses within three months. Regulations under the operational plan would have to give detail about the staffing levels the commission considers appropriate.
	A major concern about the Bill—expressed by Janet Allbeson of One Parent Families, who gave evidence to the Select Committee—is that it is very much a skeleton, and much of its detail will be in regulations, which, of course, are impossible for us to amend. It is true that CMEC will have to provide an annual report to the Secretary of State, which can be laid before Parliament. With great respect, however, I suggest that an annual report is just that; it looks back at the year that has just finished. It does not give Parliament the wherewithal to hold that new arm's length agency accountable for what it plans to do in the coming 12 months. Insisting that the operational plan be laid before Parliament would deal with many of the issues that we raised in Committee, such as the IT systems, the staffing levels or the giving of information and advice, provision for all of which is to be made later. Some of the regulations have been produced for us, as the Minister promised in Committee, but they are still only in draft and we do not have all the information.
	One of our major concerns is about staffing. The regulatory impact assessment is that CMEC's caseload will be reduced from the current figure of 130,000 for the CSA to 100,000. That may be the case. The staffing cuts already programmed envisage a 15 per cent. reduction for CMEC, taking the head-count down to 9,500 by March 2008, which in a perfect world might be okay. However, the problem that we have, and the concern that we raised in Committee, is that we have no evidence yet as to whether the case load will reduce as quickly and as drastically as is envisaged in the plan.
	We argued in Committee that there should be no reduction in staffing levels until CMEC has proved that it is functioning at the required standard. One of our concerns is that a new series of arrangements will have to be put in place, a new series of advice and information will have to be set in train, and new cases operating under the third type of child maintenance system will have to dealt with—at the same time as dealing with the huge historic debt and the nearly 900,000 non-resident parents who are in arrears. If that happens, and the staffing reductions continue, Parliament will have no recourse to hold CMEC to account.
	It is unfortunate that so much of the detail of how CMEC will operate has not been included in the Bill, although both Opposition parties moved amendments to try to change that. The new clause would make CMEC more accountable to Parliament. The new commissioner has already been appointed, despite the Prime Minister's statement about appointments being approved by Parliament. That has not happened in this case. The rest of the board, however, has not been appointed, and the House should have some say in how CMEC is going to be run. Giving it a statutory duty to present to Parliament an annual operational plan that looks forward not back—which is what we believe that the annual report will do—will give the House a proper opportunity to make sure that, at the third attempt, following the setting up of the Child Support Agency, CMEC delivers on its objectives.
	Although we have signed up to the broad brush of what the Government are trying to do, we believe that a lot of the detail has still not been filled in—detail that is vital to the success of CMEC. I am talking about staffing levels, IT support, and the provision of information and advice. None of those things are decided yet. If the operational plan were laid before Parliament, there would be an opportunity for Members on both sides to contribute positively to ensuring that CMEC gets the start that we all want. I hope that the Minister will support the new clause, which is not controversial. Implementing it would involve no additional costs. However, it would ensure that hon. Members could play a full part in ensuring that CMEC delivers on its objectives.

Michael Weir: In principle, I support what hon. Members are trying to do. Like other hon. Members, I have many constituents—mostly, but not exclusively, women—who are owed huge debts by absent parents. Those absent parents have been chased for many years, but, to date, there has been little success in obtaining the money. However, there is one point that gives me some concern. The question of how the historic debt arose was raised during the evidence session in the first sitting of the Public Bill Committee. In particular, in the early days, if the CSA could not get in touch with somebody or somebody did not respond, it would often put in an assessment on the basis of an assumed income, which was much higher than the person's real income. As a result there is a large historic debt, going back many years, based on an income that the person who owes the debt never had. One could argue that that is the person's own fault for not dealing with the CSA in the first instance. However, it raises the question of what we are going to do about setting out the true level of historic debt.
	When we asked Lord McKenzie about that point in the evidence session, he said:
	"We would like as many of those old debts to be cleared as possible. Obviously, that is quite resource-intensive...One of the things that it is proposed we do is, rather than write off debt, create a provision for reflecting the effect of inflated or uncollectible debt in the account. However, those debts would remain in being and would not be written off until there is consent from the parent with care."
	The difficulty with that approach is that there could be a large debt that was not actively chased on behalf of the parent with care. In fact, nothing would be done with it—it would simply sit on the accounts of the CSA or CMEC. When Stephen Geraghty was asked about this, he said:
	"There comes a point in any debt collection exercise where it is a question of how much we can get. I think that we are a long way from that, but presumably the commission and Parliament will, at some point, want to consider whether they want to keep the debts going." ——[Official Report, Child Maintenance and Other Payments Public Bill Committee, 17 July 2007; c. 34-35, Q83-84.]
	There could be two types of debt: debt due to the Treasury; and debt due to parents with care. While I fully support what the hon. Member for South-West Bedfordshire (Andrew Selous) is trying to do—I do not want real debt to be written off either; I want it to be pursued—I am a little worried about how we set the level of the debt. Will we take any account of what was, presumably, inflated debt in the first instance?

Andrew Selous: As I have said, I would be happy for some compensation to be paid in what I am told is the less than 1 per cent. of cases where there is an uncomfortable grating sensation on breathing.
	Paragraph (h) of section 10 of the Court of Appeal judgment said:
	"Plaques do not in themselves threaten or lead to...other asbestos induced conditions nor...are they a necessary pre-condition for such; they do not increase the risk of lung cancer; they differ from diffuse pleural thickening; and their pathology is entirely distinct from that of mesothelioma. It is the exposure to asbestos that they evidence".
	Meanwhile, in the case of Wright  v. Stoddard earlier this year, Lord Uist said:
	"It is not that pleural plaques cause harm which is de minimis: it is that they cause no harm at all."
	But enough of the lawyers—we have heard it said that pleural plaques is a working-class disease, so what do middle-class lawyers and insurers know about it? I want to deal with the remarks of the clinicians—not the insurance companies, but the doctors who have spent their lives trying to treat people with different forms of lung illness. Dr. John Moore-Gillon, the president of the British Lung Foundation, has said:
	"Pleural plaques do not themselves 'turn malignant' and become a malignant mesothelioma. They do not in themselves cause asbestosis to develop, nor do pleural plaques increase the risk of lung cancer, and they are a different condition from diffuse pleural thickening."
	Dr. Robin Rudd, a leading consultant, has said:
	"Pleural plaques are not thought to lead directly to any of the other benign varieties of asbestos-induced pleural disease."
	Dr. John Moore-Gillon has also said:
	"This is, however, a different matter from saying that the pleural plaques in themselves give rise to an increased risk of other asbestos-related conditions. Pleural plaques do not themselves 'turn malignant' and become a malignant mesothelioma. They do not in themselves cause asbestosis to develop, nor do pleural plaques increase the risk of lung cancer, and they are a different condition from...pleural thickening."

Jim Sheridan: I intend to make only a brief contribution, as my hon. Friend the Member for Barnsley, West and Penistone (Mr. Clapham) has covered most of the main points. It has to be said, however, that this is a very emotive subject, particularly in the place where I come from—the shipyards on the Clyde. When I worked there, I could see asbestos dust in the air and I remember the foreman telling me not to worry as it would not affect us and we would be okay. I am not suggesting for a moment that the foremen were to blame, as they were doing what they were told in telling people to work under those conditions. I do blame the companies who produced this stuff and asked people to work with it. It is indeed a very emotive subject.
	I can understand where the hon. Member for South-West Bedfordshire (Andrew Selous) is coming from in that we do not have the statistics we need. However, I can provide some practical stats relating to the friends, the families and the colleagues I worked beside. When they are told that they have pleural plaques, many know exactly what the next step will be. They do not need a clinician to tell them that they are safe. They know exactly what the ultimate decision will be. I, for one, have attended too many funerals of people who were told that they had pleural plaques, only to acquire full-blown mesothelioma. I am not talking only about people in the shipyards of the Clyde, as it applies to people in shipyards throughout the whole UK, including Merseyside and elsewhere.
	I can provide the practical evidence, as I said, but I disagree with the Law Lords when they decided that those who polluted with asbestos—namely, the companies— were not responsible for people developing either pleural plaques or full-blown mesothelioma. Who was responsible then? It was the irresponsible doctors who told the sufferers that they had the disease; it was their fault for telling people that they had pleural plaques, as that is what caused their anxiety. How ridiculous is that—blaming the doctors for telling people that they are unwell? That is absolutely incredible. Certainly the people I represent, my friends and my family find it incredible: they simply cannot understand it.
	When farmers and their cattle are affected by foot and mouth or blue tongue, hon. Members fall over themselves in the House to provide compensation to farmers for their dead animals. Yet when human beings contract this killing disease, the same attention is not given to them. That is my point to the Minister. People—not many in the Chamber, but our people—are watching the debate. The Government may be going through a difficult period now, but this is the sort of issue that our people want our Government to sort out. They want compensation for being exposed to the damage that others have not been subjected to. I would dearly love to spread some asbestos dust on the porridge of the Law Lords, so that they can gain an understanding of what exactly this disease does to people.
	I am sorry if I sound emotive, but I am angry at the Law Lords for taking this decision and I am even angrier that my Government—my Labour Government—are not taking the steps that I believe they should to overturn it. I return to what I said earlier about the SNP Administration in Scotland. I wish them every success in bringing forward this legislation. I am sure that the victims and their families will wish them well.
	My only concern relates to the advice given by the two Ministers in the Ministry of Justice. If they are right and the Law Lords' decision applies throughout the UK, I sincerely hope that people are not playing politics with this. If they can overturn it—on behalf of friends and families of the victims, I sincerely hope that they can—I would hope that my hon. Friend the Under-Secretary could make some sort of compromise in the Bill to ensure that if it is successful in Scotland, it should be successful in the rest of the UK. This is still a disease irrespective of whether people live in Newcastle, Glasgow, Cardiff or Belfast; it does not matter, it is a disease that kills people. I sincerely hope that the Minister takes on board exactly what has been said today and particularly the strength of feeling expressed on the Labour Benches about how this disease can affect people. I sincerely hope for that compromise whereby the rest of the UK can benefit from any compensation agreed by the Scottish Parliament.

James Plaskitt: That is an important point, and I am grateful to the hon. Gentleman for raising it. I think that information might currently be held on that but in a non-systematic way—and I think that that is the issue. That is partly why there is the degree of debate that there is within the medical profession and elsewhere as to whether or not pleural plaques do inevitably lead to worse diseases—or, indeed, whether pleural plaques are entirely and uniquely caused by exposure to asbestos, as there is even some argument about that within the medical science community. Information is crucial, and whereas at present it is not systematically gathered there might be a case for its being so. I will say more about that in a moment.
	As has become evident as the debate on these measures has progressed, the Scottish Executive have indicated their intention to overturn the House of Lords judgment via legislation, so that people who have been diagnosed with pleural plaques will be able to raise and pursue actions for damages in Scotland. Of course, the civil legal systems in Scotland and in England and Wales are completely separate, and the question of whether to legislate in Scotland is a matter for the Scottish Parliament.
	I know that the Government's decision not to intervene in the way sought by my hon. Friend the Member for Barnsley, West and Penistone is disappointing for some hon. Members who feel, as they have said, that pleural plaques should be compensatable. I reassure them that the Government are fully committed to supporting sufferers of mesothelioma and other asbestos-related diseases.

James Plaskitt: I am grateful to my hon. Friend for underlining the point made by my hon. Friend the Member for East Lothian.

Michael Clapham: Does the Minister feel that rather than start structuring a register from the beginning, it would be worth communicating with some of the members of the Association of Personal Injury Lawyers, who already have registers? For example, Thompsons solicitors keep a register of people with pleural plaques who have contacted them so a database may exist that the Minister could bring together.
	Linking that to the point made by my hon. Friend the Member for East Lothian (Ann Moffat) abut the insurance companies, does the Minister feel that discussions should be opened up with them—after all, they are the polluter? We are talking about pleural plaques that have been caused because asbestos has invaded people's bodies, so according to the "polluter pays" principle, the insurance company should put the money forward for any scheme related to a register.
	I use the term "scheme related to a register" because, as the Minister will know, people who suffer from pleural plaques come forward for their X-rays because this is linked to common-law damages, but as the common-law damages issue has been removed, there is a need for another incentive. To incentivise people to come forward to put their names on the register, there needs to be a scheme—if that is at all possible—and that should be provided by the insurance companies. Does the Minister feel that they can be encouraged to come on board?

Paul Rowen: May I thank the minister for Government amendment No. 3, which deals with parliamentary scrutiny—one of our main concerns in Committee? The laying of directions in Parliament gives hon. Members an opportunity to raise their concerns. The other Government amendments are sensible, and we are happy to support them.
	 Amendment agreed to.

Andrew Selous: This is an important Bill, which is urgently needed to ensure that we secure a better deal for the 3 million or so of our country's children who have had to endure the separation of their mother and father. We need a more integrated agenda for supporting separated families. The Bill is an important part of that agenda, but only a part, and we could learn useful lessons from Australia, where practical support for distance parenting and the establishment of civilised ongoing contact arrangements are provided in a more integrated way than we manage to achieve in this country.
	The Bill will be judged on its success in getting more financial support flowing between separated parents for the benefit of the children concerned. At present, only one in three lone-parent families receive any support from the non-resident parent. Even where the Child Support Agency is involved, only 62 per cent. of non-resident parents with a positive maintenance liability are currently making payments. That means that 38 per cent. of parents who are expecting the CSA to enforce their maintenance payments are being let down, and the success of the Child Maintenance and Enforcement Commission must be judged on securing a swift and significant improvement in those figures. CMEC is, therefore, at the forefront of the battle to reduce child poverty, about which we learned of stalling progress this morning.
	The Bill gives CMEC much tougher enforcement powers to enforce maintenance liabilities. They will only be of any use if they are used, as the CSA has had powers in the past that it has failed to use. However, the measures in the Bill to use HMRC income tax data as the basis of assessment are very welcome and should ensure less aggravation for non-resident parents.
	In Committee, both Ministers were courteous and painstaking in replying to speeches and interventions from all Committee members and I thank them for that. I would also like to thank my hon. Friends the Members for Forest of Dean (Mr. Harper), for Peterborough (Mr. Jackson), for Weston-super-Mare (John Penrose), for Daventry (Mr. Boswell) and for Mid-Bedfordshire (Mrs. Dorries). Our two Committee Chairmen, my hon. Friend the Member for Christchurch (Mr. Chope) and the hon. Member for North-West Leicestershire (David Taylor), ensured fair play throughout. Chris Shaw in the Public Bill Office was an unfailing source of guidance on procedure to me, and my own staff, Christina Keen and Christopher Tufnell, have worked hard during the passage of the Bill. No Committee can complete its business without the invaluable work of the doorkeepers, police officers and  Hansard writers and we are indebted to them as well.
	I agree with what the Minister said about paying tribute to CSA staff. The problems that the agency has had in the past are not its fault. Frankly, they are our fault, in this House, for not setting up the arrangements properly to ensure that child support worked as it was supposed to. I welcome the Minister's commitment to Crown status, also. If that provides reassurance to those working for CMEC, it will be important to the success of the agency.
	Many outside interest groups also helped to ensure greater scrutiny of the Bill and in particular I would like to thank Janet Allbeson of One Parent Families/Gingerbread; Resolution, the family law group; Families Need Fathers; and the Association of British Insurers, in particular.
	In order for the Bill to achieve its objectives, we are going to need a significant change of culture in relation to child support in addition to its provisions. The payment of child maintenance must be seen as an important positive responsibility—the first call on a separated parent's income. The Bill must ensure a fair and efficient system to achieve that, but it will also be necessary to promote the message of positive responsibility more widely, so that those who determinedly refuse to pay feel the shame of public disapproval and do not even consider boasting about their behaviour.
	The CSA has never dealt well with the human side of separation, but its successor, CMEC, has an important opportunity to do so with the provision of the information and guidance which is established in clause 5, and in particular the wider scope for information and guidance allowed for in clause 5(2). It is my wish that the importance of establishing ongoing civilised contact arrangements and support for distance parenting be recognised in the Bill. That is not in any way to make contact a condition of maintenance, merely a recognition of the fact that parenthood is about money and time—financial support and emotional support.
	Indeed, the ongoing involvement of non-resident parents in their children's lives is likely to increase their willingness to pay maintenance. In support of my argument I would like to quote Janet Allbeson of One Parent Families/Gingerbread, who said:
	"There has been a lot of fuss about lone parents supposedly refusing contact. Well, lone parents have said to us: 'We want more contact. Why does he not get more involved?' There is a sort of consensus that, if non-resident parents can be more involved—providing it is safe, of course—it has very good outcomes for children." ——[Official Report, Child Maintenance and Other Payments Bill Public Bill Committee, 17 July 2007; c. 67.]
	I agree with every word of that.
	Part of what the information and guidance service will have to do is help separated parents cope with the reality that while marriage and cohabitation are dissoluble, parenthood is not. Divorce and separation used to be regarded a bit like dividing up an estate after someone dies. The marriage or relationship was dead, the fruits of the marriage or relationship were divided and that was the end—subject to ongoing visiting rights and child support obligations, both of which were poorly enforced. Today, around the world, there is a recognition that children need, and usually want, their mother and their father to be actively involved in their lives, as long as each parent is a positive influence and there are no concerns about child abuse or violence. Internationally, there appears to be an irreversible trend towards the encouragement of shared parenting—not necessarily with equal time, but with what is termed "substantial and significant time" in Australia. That would include, if possible, time during the school week, not just at the weekends and during school holidays.
	The information and guidance service established in clause 5 will be able to learn much from the network of family relationship centres in Australia that provide a similar service. I have mentioned Australia rather a lot, and perhaps I should declare a personal interest in that my mother was Australian. The family relationship centres have been swamped by the demand for separation services, a fact that I hope will be taken on board by Ministers as they plan the capacity of the information and guidance service. I was grateful to hear a few further details about that service from the Minister.
	A fundamental change is the proposal to end compulsory participation in CMEC by all parents with care on benefits and the encouragement of appropriate voluntary maintenance arrangements. That will undoubtedly reduce the work load of CMEC, enabling it to cope more effectively with those cases where parents want the active involvement of the state scheme.
	It is obvious that a reduction in the number of parents who separate would similarly reduce the work load of CMEC and Ministers are rightly focused on that. It would be irresponsible not to encourage the Government to do more to support healthy adult relationships as they already do in a small way with their marriage and relationship support funding. Again, the opportunities to do more are enormous and do not require significant funding, merely political will. I hope that Ministers will take encouragement that it was a Democratic President who brought in a welfare reform Act in America in 1996, one of the objectives of which was to encourage the formation and maintenance of two-parent families. Some of the results on the ground are startling, with local initiatives in some countries and some cities in America experiencing drops in divorce rates of 30 to 50 per cent. On the basis that prevention is better than cure, and in order to give the Bill the best possible chance of producing a well-working system, there should be a greater focus on early interventions to reduce family breakdown.
	I turn now to part 4, which deals with compensation for sufferers of diffuse mesothelioma. We on the Conservative Benches wholeheartedly welcome the provisions, which represent an innovative partnership between the Department for Work and Pensions and the insurance industry. Seldom can public-private cooperation have been so necessary or so important for the sufferers of diffuse mesothelioma and their dependants. The legacy of work with asbestos means that there were 1,969 mesothelioma deaths in Great Britain in 2004 and that figure will rise to around 2,400 deaths a year by 2013. Even in 2050, around 500 deaths a year are expected. One in 100 men born between 1940 and 1950 will die of the disease. Life expectancy from the onset of the condition is eight to nine months, which is why the provisions are so important in getting statutory compensation to sufferers within six weeks.
	There has been much common ground among political parties, although we have not agreed about everything on a number of important areas. Nevertheless, the Bill is a move in the right direction as far as child maintenance is concerned and most definitely provides important assistance for mesothelioma sufferers and their dependants. Conservative Members will, therefore, support the Bill on Third Reading.

Richard Taylor: May I first place on record my sincere thanks to hon. Members from both sides of the House and the Officers in the Lobby who virtually led me by the hand to ensure that I was here on time and did not miss a huge opportunity? I believe that I can speak for approximately an hour and 45 minutes, but I reassure you, Mr. Deputy Speaker, that I, too, would like to get away. I will speak for a little more than quarter of an hour, but not interminably.
	The debate provides a great opportunity for me to climb on to one of my hobby horses—the minefield of health care prioritisation. I want to speak under four headings. The first is, "Why is prioritisation necessary?" Secondly, I want to demonstrate the difficulties with prioritising health care. Thirdly, I wish to welcome the Government's attempts at it so far. Fourthly, and most importantly, I want to suggest the way in which I believe that the Government should tackle the problem and how, coincidentally, that could go a long way towards helping them rebuild the electorate's confidence after the many blows of the past few weeks.
	Why is prioritisation necessary? First, we are all living a great deal longer, so we all have a longer time to be ill—we also have a longer time, I hope, to be healthy. The second reason is the complexities of the treatments now possible. People are now surviving with long-term illness, while children with severe disabilities are surviving long beyond their late teens and early 20s, which was their lot a few years ago.
	I qualified, I hate to say, 48 years ago. When I qualified, we had only about three antibiotics; now there are myriad antibiotics. Beta-blockers had not been invented, nor had modern diuretics, ACE inhibitors—inhibitors of angiotensin-converting enzyme—or antidepressants. There were no ulcer-healing drugs. A heart attack was treated with bed rest and masterly inactivity. In almost 50 years there has been an immense change in the treatments available—treatments that patients will demand, now knowing more about them. There have been tremendous changes in the treatment of heart disease, strokes and cancer. However, we cannot afford everything in a tax-funded system with inevitable cash limits.
	In my request for this debate, I asked that it be entitled "Health care rationing". When I discovered that the title had been altered, I talked to the Table Office and was told to my amazement that the word "rationing" was not really acceptable on the front of Government business papers. I found that absolutely staggering. "Prioritisation" and "rationing" mean pretty much the same, but "rationing" goes that little bit further and suggests that some things may fall off the bottom of the list as being unaffordable. I am therefore talking not only about prioritisation, but about rationing and the things that might fall off the bottom. That is the whole point of my debate.
	I do not often quote Lenin, but in 1936 he said, "Liberty is precious—so precious it must be rationed." I obviously do not agree with him, but I shall pinch his statement and make it: "Health care is precious—so precious it must be rationed." Talking about the national health service's current surplus of £1.8 billion, the Secretary of State told the Select Committee on Health last week that it was enough to meet "our" priorities. That is my first difficulty—whose priorities are we talking about when we talk about prioritisation? Are we talking about the elderly, the disabled, those with mental health difficulties or ethnic minorities? All those groups have been and continue to be neglected, according to recent reports by Mencap, the Joint Committee on Human Rights and the Disability Rights Commission. Are we talking about the priorities of the blind, the deaf, pregnant women, those with rare diseases, those with common diseases, those with fatal illnesses, those with emergency conditions or those with long-term conditions? Somehow we have to address everyone's priorities. That is one of the huge difficulties.
	The second difficulty to which I should like to draw attention is the power of various lobby groups. Obviously there are well-organised pressure groups for many of the major illnesses. I fully understand that and have no objection to it, but in any debate about prioritisation one must remember the other people. The illnesses that have a national service framework or national clinical directors, or that have achieved national priority status obviously have a huge advantage. I am not saying that that is wrong, but we must remember the others. I remind the House of what the hon. Member for Newport, West (Paul Flynn) said in his superb 10 commandments for MPs, in his little book "Commons Knowledge". Two of those commandments were that we must
	"Seek the silent voices"
	and
	"Serve constituents, the weak and neglected".
	Those are the very people we have to seek out; we must ensure that we take their concerns into account. I would much rather call a spade a spade and talk about rationing.
	What have the Government done so far? I shall mention NICE, but I shall not go into much detail. As you will know, Mr. Deputy Speaker, the Health Committee has completed its second inquiry into NICE and is working on its report now, so I would be in huge trouble if I leaked any of it. However, we produced a report on NICE in 2002 and I shall read one of our recommendations set out in paragraph 134. It states:
	"Prioritisation of healthcare spending is an issue of overwhelming importance, and during the course of this inquiry it has become clear to us that a more open debate on healthcare prioritisation needs to take place. Our inquiry has persuaded us that, with so many competing interests vying for attention and funding in an area where resources are finite, it is not sufficient to have implicit healthcare prioritisation. We feel that NICE has been laid open to unfair criticism in respect of the 'rationing' debate and as a consequence of the lack of clarity... here."
	What else have the Government done? Before having a debate on priorities, one has to ensure economy and efficiency. Here, the Government have made a very serious attempt—or the beginnings of one—with their paper, "Better Care, Better Value Indicators". I thoroughly welcome the examination in it of matters such as length of stay, days of admission before an operation, certain surgical procedures and whether they should be done at all, and the prescribing of generic drugs, particularly the statins. These better care, better value indicators have shown a tremendously wide range of performance between primary care trusts and acute trusts, for example. If the quality of service in respect of the indicators were improved to the top 25 per cent. of PCTs and acute trusts, there could be potential savings of £2 billion. I understand that there are further indicators in the pipeline, which I hope will be examined carefully and, if comparable to the first ones, wholeheartedly welcomed.
	At the Health Committee last week, the Secretary of State listed four ways of saving money: best practice, which must, of course, be evidence based; better procurement, cashing in on economies of scale; community-based services, which are obviously cheaper than hospital-based ones; and, of course, the whole issue of drug pricing. The Government are absolutely right about that and all sensible economies and increases in efficiencies must be made, yet it is still a bottomless pit, so I think that rationing is necessary.
	Let me continue briefly with some of the unacceptable results of the current situation. I shall talk about postcode rationing, which, I am afraid, does exist and leads to obvious inequalities and inequities across the NHS. A new anti-cancer drug called Sunitinib prolongs the lives of people with renal carcinoma. In some parts of the country, even though the drug has not gone through NICE, it is available; in other parts, including mine, it is not available. It is very hard for people in my area to understand that when they read about the huge surpluses in the NHS and they know people in different parts of the country close at hand who can get these extra few months of life, while they cannot.
	Another example is the use of cochlear implants for the very deaf. I am afraid that I made a rather tactless mistake in this connection. One of my constituents badly needs cochlear implants, and I was stupid enough to write to her and compare her need with people's need for Sunitinib. As might be imagined, I got a very large flea in my ear. I shall read some of my constituent's excellent letter to the House. She wrote:
	"I think it is unfair to compare my case with cancer patients. I am a person with a severe hearing disability and looking for prosthetic Cochlear Implant in order to improve my quality of life. Does the PCT put a limit each financial year for the provision of artificial limbs or eyes? Do they limit the number of hip and knee replacement procedures even cataract operations to improve failing eyesight? I would like to suggest that everybody should put earplugs in for a day and see how they get on trying to live their normal day either at home or work!"
	She went on to say that my PCT in Worcestershire had
	"the worst record for funding Cochlear Implantations in the whole country."
	In another paragraph, she wrote:
	"Regardless of Worcester PCT's financial position, at a time when the NHS has never been better funded with taxpayers money, you must agree with me that it is completely unacceptable for the PCT to reduce funding for Cochlear Implantation to the detriment of people with a major disability. I am sure the Government and the Minister of Health in particular, in addition to the RNID, would find this completely unacceptable."
	Further examples are treatment for wet age-related macular degeneration, which was covered very thoroughly by a debate in Westminster Hall last week, and fertility treatment. We hear from gynaecologists and obstetricians that fertility treatment varies strikingly across the country. Whether that variability of provision is due to better resourcing of some trusts or to better management I do not know, but I believe that there must be an open debate to decide whether those treatments should be available to everyone, and, if so, what must go in order to pay for them.
	It is sad that Members of Parliament are thought to be able to influence prioritisation. I for one was disappointed by what happened with Herceptin, when the Institute for Health and Clinical Excellence appeared to be rather hijacked by a previous Secretary of State. Although it is clearly right for people to be given Herceptin in certain circumstances, it seemed that the whole method had been circumvented, which led constituents to think that Members of Parliament can circumvent the process. That cannot be right, and there should be no need for it.
	How can we make progress? First, we must face up to the problem. Everyone agrees that the NHS must be free at the point of delivery, and it is marvellous that everyone agrees with that, but can provision actually be comprehensive? Sadly, I fear not. However, the appropriate party is in government, and perhaps its members will follow Bevan's words of 1949:
	"The language of priorities is the religion of Socialism."
	Hopefully they are on the same wavelength, believing that priorities and prioritisation may improve the equality of health care.
	As I have said, we must first focus on all the economies. That is why it is good to see in the Government's proposed Bills a focus on prevention and a focus on public health. We must try to persuade the Government that more money spent on prevention in the short term, even if that has to be taken away from acute care, will save money in the long term. We must also focus on staff levels and quality of care, because at present immense sums of money are wasted on litigation, and even if we have to do more rationing of acute care now to improve prevention and to cut down litigation, that could be helpful in the long term.
	An example of the tremendous power that some lobby groups have is demonstrated by the cancer reform strategy published today. Obviously, I have not had time to read every word of it, but I was glad to see when glancing through it that there is an emphasis in it on prevention, which will, of course, not cost that much. It is also keen that one should understand when rationing is necessary and when decisions are not those of rationing.

Richard Taylor: I thank the hon. Gentleman for that intervention, and I agree with what he says. I have, however, been circumspect in talking about NICE, and I am hoping that our inquiry and the report will address some of those questions, so I will not be drawn into addressing this matter further at present.
	I was about to explain a little in respect of the cancer reform strategy. In the section on community-based prostate health clinics, there is the following significant sentence:
	"Improved support for men in making decisions about further investigation or treatment would not be a form of rationing, but rather a way of ensuring that men have the best possible information and support when making difficult decisions."
	There is rather a move to imply that a PSA—prostate-specific antigen—screening programme is not being rolled out nationwide because of financial difficulties, but that makes it clear that that is not the reason why, and that the reason is because the case for screening is not entirely proven as yet.
	All of this calls for great courage from the Government. To open an honest public debate about priorities, admitting that some treatments might fall off the bottom and get rationed out, will be difficult for the Government to consider. Vitally, however, this subject is also important the other way around, in respect of the £1.8 billion surplus. I know we keep on being told that it is only 2 per cent. of the whole NHS budget, but £1.8 billion is still a lot of money to anybody, and after the restoration of education budgets and the ending of the vacancy freeze on staff one would think there should be some left. I think that people should have a say in what the surplus is used on. For me, one of the high priorities would be to reduce the postcode rationing.
	I shall briefly consider what could be removed from health care provision and what could be given a low priority. I had hoped that we were still using lots of medicines that did nothing, but NICE told us in an open session of the inquiry that it had looked at this matter and found that few drugs that do nothing were still being used. That is sad, because I remember as a houseman writing up in dog Latin super things such as mist. ipecac. co. That was a delightful medicine whose very taste made one feel better. It was supposed to stop one coughing, but it rightly fell out of use ages ago.
	Should we provide cosmetic surgery in respect of tattoo removal or varicose veins? Should we provide travel immunisation or, more controversially, gender change operations, vasectomy reversal or surgery for obesity? What about surgery for some conditions if the patient continues to smoke or drink? That is just the start of a list. How should we take it on?
	 Hospital Doctor, one of these widely circulated free newspapers for hospital doctors, recently reported on a survey of medical opinion, and it called for an urgent review of NHS rationing. Admittedly its evidence was mostly anecdotal evidence of deaths, suffering and complaints resulting from our higgledy-piggledy rationing by local availability of resources.  Hospital Doctor called on the Government to commission an independent review of how treatment is rationed in the NHS. It specifically wanted:
	"More transparency in how rationing decisions are reached and communicated; Stronger and wider-ranging guidance either from NICE or another independent source; Less political interference, from MPs campaigning for certain treatments to individual primary trust management decisions."
	Those are all reasonable aims.
	The Royal College of Surgeons has joined the debate. Recommendation 2 of its response to the British Medical Association's discussion paper, "A rational way forward for the NHS in England" referred to core services. It stated:
	"There are difficult choices to be made regarding the deployment of NHS resources. This College believes that decisions on priority setting, like those on reconfiguring services, should be made primarily on the basis of clinical need and not in the interests of financial or managerial expediency. There must be an open and honest debate about the services which are freely available on a national basis, those which require some form of co-payment and those which cannot be provided by the state."
	The college goes on to draw attention to some of the obvious difficulties that we would encounter were we to embark on such a debate.
	My challenge to the Government is to accept that the NHS is potentially a bottomless pit, and that most people want a tax-funded service free at the point of delivery but that a fully comprehensive service is probably impossible. We thus need to have a debate on the top priorities—the core services—and the lesser priorities, some of which might fall off the bottom of the affordable scale.
	An open and honest debate on the issue might restore some confidence in the Government and show that they are prepared to listen. A debate would also give the Government the chance to demonstrate that they can take advice—something that was thrown into doubt by the treatment of the Home Office Minister in the House of Lords recently.
	If such a debate took place, headlines such as those in  The Guardian today might no longer be possible. Two examples were, "Prospect of moving to a care home frightens two thirds of Britons" and "NHS ignoring human rights of people with learning difficulties". Perhaps the Minister could persuade his ministerial colleague in the House of Lords to add this dimension to his review of the NHS. His vision is of
	"a world class NHS focused relentlessly on improving the quality of care".
	I cannot argue with that, but I wish that we could add to the vision how that is to be achieved and how we can tackle the inequity that exists. We must recognise that we cannot afford everything, and the consultation must address the issue of prioritisation or rationing. I have demonstrated tonight how much support there is for doing so.

Ivan Lewis: I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. The House benefits from his clinical expertise and long history of fine service to the NHS. He has also become gradually aware of how to be a streetwise politician, as is clear from some of his recent contributions to debates.
	The hon. Gentleman entered the House in the first place through an attempt to have an honest and open debate about health care in his local community. He campaigned very emotively on behalf of the local hospital and succeeded in removing the sitting MP. The hon. Gentleman will therefore understand why there might be parameters to people's willingness to be open about the need for change and transparency in the NHS. However, I will not hold that too much against him this evening.
	The hon. Gentleman raises several fundamental issues that we need to address now and in the future, given the changing nature of our society and of health care. It is important to contextualise the debate. This Government have put in an unprecedented level of resources over a sustained period, in terms of the history of the NHS. As a consequence, we have had a massive improvement in patient care, beyond all recognition compared with the state of the health service only 10 years ago.
	Between September 1997 and September 2006, nearly 36,000 more doctors and nearly 80,000 more nurses were employed in the NHS. Waiting times are now at the lowest levels since records began. Only five years ago, thousands of patients waited for anything up to 18 months for in-patient treatment; now, the vast majority are seen and treated within six months. By 2008, all patients will be treated within 18 weeks of referral from a GP in the vast majority of circumstances.
	More than 99 per cent. of patients with a suspected cancer are seen by a specialist within two weeks of being referred by their GP, which is a huge improvement over only 63 per cent. in 1997. More people than ever before who are diagnosed with cancer begin their treatment within a month of diagnosis. We have increased the number of cancer specialists by 45.6 per cent. since 1997, while cancer mortality in people under 75 fell by nearly 16 per cent. between 1996 and 2003. Leaving aside the statistics however, that means that 50,000 lives have been saved.
	We are proud of the cancer reform strategy that we announced today. It puts great emphasis on prevention, but we want to go even further in terms of the advances that have been made.
	In the hon. Gentleman's community, Worcestershire primary care trust will receive allocations of £617.7 million in 2006-07 and £679.3 million in 2007-08. Those allocations represent an extraordinary cash increase of £130.4 million, or 20 per cent. over two years, although it is about the national average.
	The hon. Gentleman quoted Lenin and Nye Bevan. I shall not be able to emulate him in that respect, but I shall mention that John Lennon wrote "Imagine", a song that gave an idealistic view of the world and which said that we should be optimistic and positive about the future rather than grudging, cynical and negative. At different stages in the development of the NHS there have been people who have preached doom and gloom; they said it was not doable, not possible or no longer viable. Much of the reform in the Conservative Government's agenda for health between 1979 and 1997 was underpinned by the notion that if they eroded public confidence in the national health service that Labour created, and which we believe in, over time the public would stop believing in the NHS, too, and wholesale privatisation would be the inevitable consequence. I am delighted that they were never allowed to finish their mission. In any case, the British people would have rejected it overwhelmingly.
	There is no doubt that we live in a changing society and the health service cannot function in isolation. People are living longer, and they suffer from more challenging conditions. There are medical and technological advances. Patients have different expectations nowadays from 10, 15 or even 20 years ago, so the hon. Gentleman is right to say that the health service has to adjust, not just to present-day realities, but to our changing society.
	The hon. Gentleman says that people with learning disabilities are not treated properly in the NHS and that there is a failure to respect the dignity of older people. He should talk to some of his professional colleagues and the managers in the service about why some of those things happen. It is not because there are not enough resources to fund the system properly. That cannot be used as justification for not treating older people with dignity and respect and not treating people with learning disabilities properly. We should not entirely let NHS management and professionals off the hook in terms of their responsibilities to some of the most vulnerable patients. It is important that we talk about quality, accountability and responsibility.
	A number of factors will influence an equitable and fair NHS in the future. The building blocks are in place. NICE is world-class by any comparable standards, and I thank the hon. Gentleman for being positive about the role of NICE, as well as for being realistic about some of the difficulties and tensions the organisation faces. NICE is consulting on its technological appraisal methodology, and I urge hon. Members and members of the public to comment on whether that methodology should be changed in any way.
	Whatever the system, if it comes up with popular results, an organisation will be applauded to the heavens, but when its decisions are more controversial or unpopular the organisation will inevitably attract significant flak and criticism. That is why we must be consistent in our support for the integrity and independence of NICE. The organisation is relatively young and new, but it does a very good job indeed.
	The other factors that will influence the long-term sustainability of the NHS, its universality and the comprehensive nature of what it offers people, include resource allocation. We are consulting on the resource allocation system in the NHS. What are the characteristics and ingredients that make up the formula that determines how resources are distributed across the system? Factors such as the nature of a local population, need within the community, poverty, the number of elderly people, sparsity and rurality are all important when looking at whether the distribution of resources across the system is as fair as possible.
	The hon. Gentleman rightly raised the question of where we spend the existing money. As the Minister with responsibility for social care, mental health and children's health, I think that there is an issue about significantly shifting resources in the national health service from acute NHS care to early intervention and prevention, and community-based services. That requires courage from people such as the hon. Gentleman, who is respected for his clinical judgment; such people should argue fiercely that no change is not an option in terms of best patient care and that the position of Her Majesty's official Opposition, which appears to be a moratorium on any change to services, is highly irresponsible and not in the best interests of patient care.

Ivan Lewis: I agree with my hon. Friend about most things to do with the health service. He is absolutely right. It is important to understand that we spend large amounts of taxpayers' money on health. Health is a massive concern to every voter and citizen. The notion that comes from some clinicians—I do not think it comes from the hon. Member for Wyre Forest—that politicians should butt out entirely of decisions about the national health service is disingenuous.
	We have to define appropriately the respective responsibilities of the different players in our national health service and its relationship with other bodies. I will come to that in a moment. What is the responsibility of the Department of Health nationally, of Ministers and senior officials in terms of policy, and of strategic health authorities and primary care trusts? What are the responsibilities of front-line clinicians and other NHS staff? What power—and accountability—should we give to individual patients, users and carers, as well as local communities, when it comes to influencing decisions that affect the NHS and social care in their areas?
	We know that there has been an increasing role for overview and scrutiny committees and local authorities, and we want to see that role expand. What is the proper place for local elected members to have some sort of influence? I am not sure that we want to have a stale debate about whether local government should run the NHS or whether the NHS should take over social care, because inevitably we will then get into debates about organisational restructuring, which could lead us down a road that we do not need to go down. However, as the hon. Member for Wyre Forest said, we have to address honestly accountability, respective responsibilities and relationships among the different players.
	I was talking about shifting resources from acute care to early intervention and prevention. It is important that people do not see this as ideology, because it is also about patients' choice and expectations. The vast majority of people want to remain in their own homes for as long as possible. Medical and technological advances—the hon. Gentleman referred to this—mean that there is no rhyme or reason as to why many treatments that have historically and traditionally been undertaken in hospitals need to take place in a hospital building. Equally, we need to reassure the public that our investment in primary and social care, and community-based health provision, will be put in place so that the shift in resources does not lead to a diminution in services, but results in things being done differently, with a stronger approach on patient care.
	In the context of finite resources, we have a responsibility to consider health inequality. It cannot be doubted that the family into which citizens are born and the postcode area in which they happen to live can have a dramatic impact on their quality of life, life expectancy, and health and well-being. Part of being honest and transparent in the debate—Nye Bevan would be proud of a Labour Minister saying this in 2007—is not apologising for recognising that in any funding allocation system, it is entirely appropriately to focus a significantly greater proportion of resources on those in the greatest need. We need to make it clear that people in the greatest need can be living in relatively affluent areas, so the way in which we target additional resources to address health inequality is also a challenge.
	There is a question about the relationships among the national health service, local government, social care, public health and the wider range of services that contribute towards citizens' well-being in local communities. If we are going to move towards prevention and early intervention, and recognise that the ability to have a job has a direct impact on many people's health and that their ability to access education and training contributes to their well-being, we will need a step change in the integration of local government, the NHS, the voluntary sector and the private sector in every local community. Over time, we need a more integrated approach on not only the commissioning of services, but their planning and, in many cases, co-location. I say gently to the hon. Gentleman that it is important that the NHS understands that many of its objectives will be achieved only through its connectivity with local government, the third sector and the private sector.
	Practice-based commissioning will be incredibly important. On the basis of a population needs assessment, we will be giving practices a lot more power to commission services. That is another vehicle to ensure equity of access as well as quality of care. The priorities in the NHS operating framework obviously determine the view of the chief executives of PCTs and provider trusts on what is important when allocating resources and focusing on delivery. The operating framework is crucial, as are the outcome framework for the NHS and the new performance and outcome framework for local government. It is important that we try to secure synergy in a world in which we are trying to achieve more of our policy objectives through local area agreements. Such agreements bring local agencies on the ground together around shared objectives, shared accountability and shared responsibility.
	I urge the hon. Gentleman and my hon. Friend the Member for Bristol, North-West (Dr. Naysmith), as members of the Select Committee on Health, to start conducting serious analysis on the new performance framework locally and its implications for securing the health and well-being of a local population. All of us—Ministers, officials, Health Committee members and parliamentarians—need to start looking holistically at the health and well-being of citizens and local populations. We will be able to do that only if we examine not only connectivity among the NHS, local government, the voluntary sector and the private sector, but the power, control and choice that we put in the hands of patients, users and carers.
	Lord Darzi is undertaking tremendous work in the other place on the next stage in the national health service's transformation. The question is how we move from having fixed the NHS and rebuilt its foundations—the Government are proud of that—to creating a world-class, cutting edge national health service. A couple of weeks ago, my noble Friend Lord Darzi became probably the first Minister in history to have saved two lives in 48 hours. I cannot think of many politicians who have been praised for saving one person's life, but to save two in 48 hours must be a historic achievement. Lord Darzi is a massive asset to our ministerial team and to our development of national health policy. His views and aspirations are based on his everyday experience; the same is true of the hon. Member for Wyre Forest. Lord Darzi is a world-class clinician in his field, so it is important that he is at the heart of what we are doing, and is working closely with an excellent Secretary of State to make sure that we go from having fixed the NHS to creating a world-class system.
	The Secretary of State has asked me to lead the work on the case for an NHS constitution. The notion of a constitution is exciting because it would be an important vehicle allowing us to enshrine the rights and responsibilities of patients in the NHS, the relationship between central Government and the NHS regionally and locally, and the NHS's connectivity with other agencies on health and well-being. I have been asked to examine the issue. We will talk to people, and I invite the hon. Gentleman to submit any ideas that he has on whether we ought to have a constitution, and if so, on what the content ought to be. I hope that his contribution will be slightly more constructive than that of Her Majesty's official Opposition. They produced a constitution that they said would give clinicians independence, and said that they were creating a board that was at arm's length from Government. When they were asked to whom the board would be accountable, the answer was the Secretary of State for Health—a curious notion of independence and transparency. The debate on whether we ought to have a constitution, and what should be in it, gives us an opportunity to address some of the legitimate points that the hon. Gentleman has raised.
	The hon. Gentleman spoke about patient, carer or user pressure. In a healthy democracy, there will always be such pressure. It is the responsibility of the elected Government and parliamentarians to absorb it, to listen to the heartfelt views of people who feel passionately about causes and to make decisions that are in the best collective interest. That is at the heart of the responsibility of an elected Government in a democratic society, and at the heart of how responsible parliamentarians ought to behave. I am delighted to say that we will never live in a country in which pressure groups have stopped fighting for the things that they care about most. Sectors may still feel that they are the Cinderella, including the mental ill-health and learning disability sector, and historically, to some extent, the child health sector. Carers increasingly tell me that the health service does not treat with sufficient respect care partners who look after older or disabled people. We should not be afraid of patient pressure; we should welcome it. Our job is to weigh up all those views and all that passion, and to welcome and encourage it, but then to make the difficult judgment calls that elected politicians are charged with making.
	The Government are proud to have created the national health service. We are proud of the fact that we have rebuilt its foundations and rescued the NHS. One of our fundamental values and principles is that the NHS must remain free at the point of use, irrespective of means, and funded through general taxation. That is non-negotiable—there can be no compromise or dilution—but I believe that we can retain that fundamental set of values and principles while addressing responsibly and seriously the legitimate concerns voiced by the hon. Member for Wyre Forest about the changing nature of society and the massive medical and technological advances that have taken place and will continue to take place. As part of the Lord Darzi process, I look forward to ensuring that we have the building blocks in place to move from an NHS whose foundations have been rebuilt to a world-class national health service.
	 Question put and agreed to.
	 Adjourned accordingly at half-past Nine o'clock.